No Surprise ACT:     What is it about?  click here for sample forms

The American Psychology Association legislation the SURPRISE everyone Act.    It is a great irony that the No Surprises Act comes as a surprise indeed to the overwhelming majority of the mental health clinicians and clients to whom it may likely, in a matter of days, apply. The Act will no doubt be of significant assistance to patients seeking emergency care for urgent crises, who will be protected from incurring enormous ancillary and out-of-network fees unawares. This step forward in patient protection will be counterbalanced, however, by its potentially devastating effect upon mental health and mental health services.  ( )

APA legislation. The LPCA Board of Directors scheduled an emergency meeting as APA is promoting that clinical professionals need to comply, with the federal legislation they just got passed, which it appears to be a conflict when reading the language.
Here is what we know so far:

No Surprises Act created by the American Psychological Association, APC is also the rulemaking body

OPEN LETTER to Dr. Beverly Smith, President of AMHCA from Nona L. Wilson, PhD., LCPC Core Faculty, [email protected], Co-Chair, Education Committee, PSiAN, Evanston IL

Below is a petition related the Act developed and circulated by PSiAN, a multi-disciplinary organization that advocates for therapies of depth, insight, and relationship (find out more about PSiAN here:

The petition draws attention to the very real potential for harm to clients and to mental health services broadly. Though the petition is directed to APA and its role, PsiAN welcomes signatures from all mental health professionals, including counselors, social workers and psychiatrists. Practicing clinical mental health counselors and their clients will be no less affected by the No Surprise Act

PsiAN's letter on The No Surprises Act

What we are witnessing is yet another instance in which algorithms that apply, if problematically, to physical medicine are imposed upon mental health delivery systems to which they do not, to the likely benefit only of insurers.

The ways in which this Act could undermine mental health service delivery, as these are only beginning to emerge, are manifold. The least of the burdens the Act imposes is the prospect of adding additional paperwork demands upon practitioners, who already communicate their per-session fees to patients, who tend to be overwhelmed by paperwork demands already in place, and whose reimbursements have been steadily declining in real dollars while the cost of living has risen.

If mental health clinicians are held to the specific rules announced last October, we can anticipate serious disruptions to patient care:

It would be clinically and morally problematic for therapists to diagnose patients in advance of meeting them (even though doing so is not explicitly prohibited by psychologists' ethics code), and to inform them of conjectural diagnoses in advance of one-on-one discussion regarding them.

An extended process is frequently necessary to establish an accurate diagnosis, and much harm, sometimes irrevocable, can be done by offering an incorrect one.

It is impossible for therapists to offer any meaningful estimate of the length of treatment, which varies widely depending upon complex patient variables.

Because psychotherapy has a developmental arc, and because patients are often offered unrealistic expectations of mental health treatment course by the media and even by the internists and other medical professionals who refer them, they often cannot appreciate either the depth and causes of their distress or the process it would take to remediate it until they have become clearer regarding both factors. For these reasons, it is highly likely that an immediate confrontation with facts regarding duration and expense will discourage treatment, especially for those who need it most.

Psychologists often treat individuals struggling with psychosis and other severe challenges that render trusting treatment providers difficult, necessitating delicacy and tact in establishing sufficient confidence in their practitioners. Especially for these individuals, such a request for consent would be significantly distressing rather than reassuring.

Most often, those who require intensive treatment need time to reconcile themselves to it. It is not uncommon for the most disturbed patients to most grossly underestimate the treatment they need. They will more likely forgo treatment entirely than embrace it, even in the form of an estimate, prematurely.

Due to the stigma against accessing mental health services, many people do not endorse the extent of their difficulties early in treatment. Rather, these only emerge over time.

It should be clear to the APA that this Act as they have interpreted it to their members and others would deal a decisive blow to mental health service provision, and particularly to those who provide out of network services. Other mental health professional organizations have responded in ways that are more supportive to their members.

For example, in this letter from the American Psychiatric Association, the organization supports the patient protections of the Act while highlighting how the Act might exacerbate access to inpatient care, and how insurance companies might try to benefit from loopholes.

The Clinical Social Work Association provides this guidance ) and a Good Faith Estimate template for its members. The template is more streamlined than the one from the American Psychological Association, and does not include controversial elements, such as total annual projected cost of therapy or a diagnosis.

To address our concerns, PSian is requesting the following of the APA:

1. Offer a clear explanation of its stance and its input regarding the processes of creating the Act and of rulemaking

2. Explain its seeming reinforcement of the need for sweeping changes among practitioners, especially when there are striking ambiguities in the Act, and as other disciplines' professional organizations view the provisions of the Act as questionable in its application to private practitioners, or as requiring fewer adaptations.

3. APA - Amend its templates and advice to practitioners to align them more closely with those offered by other disciplines' professional organizations. For example, templates should require an initial disclosure of per-session fees in lieu of global or ongoing estimates of treatment cost.

4. Write letters to CMS and legislators – and take the lead in drafting a letter for the Mental Health Liaison Group – that lay out a clear argument as to why mental health professionals, including private practitioners, should, if they aren't already, be exempted from the Act. If any mental health professionals are already exempt, the APA should demand that this be made explicit in the Act.

5. Take an explicit stand to protect Out of Network (OON) patients and therapists from insurance networks' interference. Restricting the rates agreed upon by OON patients and therapists is no remedy for the inadequacy of many networks, whose panels are insufficient because they refuse to reimburse mental health professionals reasonably and/or demand intrusive oversight of medical necessity with an unduly heavy reporting burden.

6. Clarify explicitly that providers need not negotiate a rate with insurers for out of network services, nor abide by the in-network rate. It is unrealistic for practitioners to be expected to negotiate with each insurance company for which they are out of network., or to ascertain insurers' in-network rates to avoid allegations of balance billing. Many therapists report wait times to speak to representatives in terms not of minutes but of hours, and can anticipate that in-network rates will be less than what those of their patients who are wealthy can easily afford.

APA must make a choice as to whether or not to be visible and vocal in its support of patients and clinicians when this support is most needed. We eagerly await what we hope will be significant next steps to remedy the harmful consequences of what otherwise promises to be a much-needed Act.

Regards, Nona L. Wilson, PhD., LCPC
Core Faculty, [email protected], Co-Chair, Education Committee, PSiAN, Evanston IL